<!DOCTYPE html>
<html>
<head>
	<meta http-equiv="Content-Type" content="text/html; charset=utf-8"/>
	<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=no"/>
	<meta http-equiv="cleartype" content="on">
	<title></title>
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</head>
<body>
<div class="wrapper" id="wrapper">
	<div class="header">
		<input class="header-button-left" type="button" value="Retour">
		<span>Mot de passe oublié?</span>
	</div>
	<div class="content" id="content">
		<ul class="form-list">
			<li class="form-table-row auto">
				<div class="row-text-left">
					Veuillez renseigner les champs suivants,<br/>
					et un email vous sera envoyé avec un nouveau<br/> mot de passe.
				</div>
			</li>
			<li class="form-table-row line30 top-gap">
				<div class="row-text-fix">Email :</div>
				<input type="text" class="row-input" value="" name="emailInfo">
			</li>
			<li class="form-table-row line30">
				<div class="row-text-fix">Date de naissance :</div>
				<input type="text" class="row-input" value="" name="emailInfo">
			</li>
			<li class="form-list-footer top-gap">
				<input type="button" value="Valider" class="row-button-blue right">
			</li>
		</ul>
	</div>
</div>
</body>
</html>